Provider Demographics
NPI:1760992788
Name:MILWAUKEE PSYCHOTHERAPY COLLABORATIVE
Entity Type:Organization
Organization Name:MILWAUKEE PSYCHOTHERAPY COLLABORATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:SMOTHERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-367-9413
Mailing Address - Street 1:9120 W HAMPTON AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-4960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9120 W HAMPTON AVE STE 212
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-4960
Practice Address - Country:US
Practice Address - Phone:414-367-9413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2973103TC0700X
WI303957103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100046393Medicaid
WI43599400Medicaid